Search Results (59)

Elevated levels of atherogenic lipoproteins are known to be associated with an increased risk of incident and recurrent cardiovascular events. Knowing that the immediate post-acute coronary syndrome (ACS) period is associated with the maximum risk of recurrent events, the gradual escalation of therapy allows the patient to remain above the targets during the most vulnerable period. In addition, the percentage of lipid-lowering levels for each class of drugs is predictable and has a ceiling. Hence, it is prudent to immediately start with a combination of lipid-lowering drugs following ACS according to the baseline lipid levels. Multiple studies with injectable lipid-lowering agents (PCSK9 inhibitors) such as EVOPACS, PACMAN MI, and HUYGENS MI have shown the feasibility of achieving LDL-C goals by day 28 and beneficial plaque modification in non-infarct-related coronary arteries. Recently, a study from India demonstrated that an upfront triple combination of oral lipid-lowering agents was able to achieve LDL-C goals in a majority of patients in the early post-ACS period. This notion is also supported by a few recent lipid-lowering guidelines advocating for an upfront dual combination of a high-intensity statin and ezetimibe following ACS. Henceforth, the goal should not only be the achievement of lipid targets but also their early achievement. However, the impact of this strategy on long-term cardiovascular outcomes is yet to be ascertained. Full article

Objectives: The goal of this study was to investigate lipid goal achievement rates in very high-risk patients over six months using high-intensity rosuvastatin or rosuvastatin/ezetimibe combination lipid-lowering therapy. Methods: This prospective, observational study was conducted on the patients of 150 general and 60 specialist practices. Our analysis included 3017 patients (47% women) who completed six months of therapy. Of these, 55.5% had pre-existing cardiovascular disease, 35.6% had cerebrovascular disease, and 20.4% had peripheral vascular disease. Results: At six months, in patients receiving rosuvastatin monotherapy (20.5%), the 1.8 LDL-C achievement rate was 37%; in those taking the fix rosuvastatin/ezetimibe combination (63.7%), it was 52%, and the 1.4 level attainment proved to be 11% and 22%, respectively. The rates of LDL-C reduction of at least 50% were 32% and 42%, respectively. Overall, non-HDL-C goal achievement rates were higher than when LDL-C was calculated using the Martin–Hopkins or Sampson methods but similar to those calculated with the Friedewald formula. When patients were stratified by triglyceride quartiles, non-HDL-C goal achievement rates were significantly higher (p < 0.001) in cases with triglyceride levels below 1.2 mmol/L. Conversely, Friedewald-calculated LDL-C (F-LDL-C) goal achievement rates were significantly higher (p < 0.001) in patients with triglyceride levels above 1.7 mmol/L. Conclusions: Our findings suggest that the consistent use of fixed high-intensity statin and ezetimibe combinations can improve lipid goal achievement. However, comparing the achievement of LDL-C goals (calculated by three methods) and non-HDL-C goals also confirmed that the common practice of automatically adding 0.8 mmol/L to the calculated LDL-C value to determine non-HDL-C leads to inaccuracies, particularly in the lower triglyceride ranges. Full article

Background/Objectives: Bempedoic acid (BA) is a novel lipid-lowering agent that reduces low-density lipoprotein cholesterol (LDL-c) and cardiovascular events. Limited real-world data on its effectiveness and safety are available. This study aimed to evaluate the utilization and clinical performance of BA in routine clinical practice. Moreover, an explorative pharmacoeconomic analysis was performed. Methods: We prospectively enrolled consecutive patients with dyslipidemia who started 180 mg BA, alone or with 10 mg ezetimibe, across five outpatient clinics in Campania Region, Italy from September to December 2023. Clinical and laboratory assessments, including lipid profile, hepatic function, and creatine phosphokinase levels, were performed at baseline and at least after one month follow-up. Side effects were recorded. Results: 111 patients (age 65 ± 9 years, 61% male) were included. At BA initiation, 70.3% were on maximally tolerated statin dosage and ezetimibe, 16.2% on ezetimibe alone, and 13.5% on PCSK9 inhibitors due to statin intolerance. BA significantly reduced LDL-c serum levels (89.9 ± 33.0 vs. 56 ± 27.6 mg/dL; p < 0.0001), with 46% achieving therapeutic targets. LDL-c decreased by 28% in patients on intensive statins/ezetimibe and by 45% in statin-intolerant patients, with reduced healthcare costs. Side effects were infrequent (10%) and reversible. Adherence was 99%, and persistence 90%. Conclusions: In our clinical pratice, BA was primarily used in high-risk patients with dyslipidemia who failed to reach LDL-c therapeutic target with statins/ezetimibe, and to a lesser extent, in statin-intolerant individuals. BA treatment enabled 54% to reach LDL-c therapeutic target. BA was well tolerated, and showed high adherence and persistence, contributing to cost savings. Full article

Background/Objectives: Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) are severe forms of stroke with high morbidity and mortality rates. HMG-CoA reductase inhibitors, commonly referred to as statins, known for their lipid-lowering abilities, also possess pleiotropic properties, including anti-inflammatory and neuroprotective effects. We aimed to evaluate the impact of statin therapy on the functional outcomes and survival in patients with ICH and SAH. Methods: This retrospective cohort study analyzed data from the Get With The Guidelines (GWTG) stroke registry at a tertiary care center, including patients diagnosed with ICH or SAH between January 2008 and June 2022. Patients were categorized based on prior initiation of statin therapy: no statin, low-intensity statin, or high-intensity statin. The primary outcome was the Modified Rankin Scale (mRS) score at discharge, dichotomized to good (0–2) and poor (3–6) outcomes. A multivariate logistic regression model controlled for age, gender, and National Institutes of Health Stroke Scale (NIHSS) score at admission. Results: A total of 663 patients with ICH and 159 patients with SAH were included in the analysis. In the ICH patients, low-intensity statin therapy was associated with significantly higher odds of a good functional outcome (aOR 2.56, 95% CI 1.247–5.246, p = 0.0104), as was high-intensity statin therapy (aOR 2.445, 95% CI 1.313–4.552, p = 0.0048). Among the SAH patients, all 39 deaths occurred in the no statin therapy group. Conclusions: Both low- and high-intensity statin therapy are associated with improved functional outcomes in ICH and may offer a survival benefit in SAH. These findings highlight the potential neuroprotective role of statins in hemorrhagic stroke. Further prospective studies and randomized controlled trials are needed to confirm these observations and to clarify the optimal use of statins in this patient population. Full article

Background/Objectives: This study assessed the proportion of secondary cardiovascular prevention patients who achieved low-density lipoprotein (LDL) cholesterol targets as per the 2019 ESC/EAS Dyslipidemia Guidelines. We also evaluated whether lipid-lowering therapies (LLTs) were adjusted in patients not meeting targets and analyzed the likelihood of these modifications achieving recommended levels. Methods: A multicenter, cross-sectional observational study retrospectively reviewed medical records of 1909 outpatients in 9 Italian cardiac rehabilitation/secondary prevention clinics from January 2023 to June 2024. Inclusion criteria included prior atherosclerotic cardiovascular disease (ASCVD) and recent LDL-cholesterol levels. Data included demographics, ASCVD presentation, lipid profiles, and LLTs. Patients at very high risk had LDL targets of ≤55 mg/dL, or ≤40 mg/dL for recurrent events within 2 years. Clinicians’ approaches to LLT modification in patients not at target were recorded, with LLT efficacy estimated based on percentage distance from LDL-cholesterol targets. Results: Of the 1909 patients, 41.3% met the LDL-cholesterol target. Predictors of achieving targets included male gender, cardiac rehabilitation, recent acute coronary syndrome, diabetes, and triple therapy (statin + ezetimibe + PCSK9 inhibitors). Conversely, a target of ≤40 mg/dL, lack of therapy, and monotherapy were negative predictors. Among 1074 patients not at target, LLT modifications were proposed for 48.6%. Predictors of LLT modification included recent ASCVD events, cardiac rehabilitation, and greater percentage distance from the LDL target, while advanced age and an LDL target of ≤40 mg/dL were negative predictors. However, only 42.3% of modified therapies were predicted to be effective in reaching LDL targets. Conclusions: Despite 2019 ESC/EAS guidelines, a significant proportion of high-risk patients did not achieve LDL targets, and proposed LLT modifications were often insufficient. More intensive LLT regimens are needed to improve outcomes in this population. Full article

Background: Treatment of CV risk factors, such as cholesterol level, represents one of the main goals to reduce atherosclerotic burden. The aim of this study was to investigate the prescriptive appropriateness of cholesterol-lowering drugs among patients who experienced an atherosclerotic CV disease (ASCVD). Methods: We investigated 155 patients who underwent cardiac rehabilitation in 2020. The European Society of Cardiology (ESC) 2021 guidelines on CV disease prevention and 2019 ESC Guidelines on dyslipidemias were followed to detect the appropriateness of prescription. SCORE2 and SCORE2-OP risk estimations were used to detect patients’ CV risk profiles. Patients were divided into three groups: 1 (n = 118) patients admitted for their first CV event, 2A (n = 18) patients who experienced a previous CV event years before, and 2B (n = 19) patients admitted for a new event with a previous CV event 2 years before. Low-density lipoprotein (LDL) cholesterol level was detected at the time of admission to the hospital, during cardiac rehabilitation, and at the first visit after rehabilitation. Results: The statistics for our study participants, with a mean age of 66.1 years, were: 72.4% overweight/obese, 63.9% diabetic, 72.5% smokers, 93.0% hypertensives, and 91.7% had dyslipidemias. In group 1, only 5.1% had a low/moderate risk, 44.1% presented a high risk, and 50.8% a very high risk according to calculators. The average LDL levels were 115.8 mg/dL (2.99 mol/L) upon admission to the hospital, 66.4 mg/dL (1.72 mmol/L) at the time of cardiac rehabilitation, and 64.8 mg/dL (1.67 mmol/L) at the subsequent medical visit. In the overall group, only 36.0% had LDL < 55 mg/dL (1.42 mmol/L). In group 1, 79.4% were treated with high-intensity statin alone or plus ezetimibe; in group 2A, the percentage increased up to 87.5%, while group 2B 33.4% was treated with high-intensity statin plus ezetimibe and 33.3% were treated with PCSK9 inhibitors. Conclusions: This retrospective study confirms the importance of properly calculating CV risk profiles. The main limitations for the efficacy of lipid-lowering drugs were: patient’s compliance, drugs side effects, lifestyle habits, and collaboration with a general practitioner. Full article

Cardiovascular disease (CVD) and ischemic stroke (IS) are the primary causes of mortality worldwide. Hypercholesterolemia has been recognized as an independent risk factor for CVD and IS. Numerous clinical trials have unequivocally demonstrated that reducing levels of low-density lipoprotein cholesterol (LDL-C) significantly mitigates the risk of both cardiac and cerebral vascular events, thereby enhancing patient prognosis. Consequently, LDL-C reduction remains a pivotal therapeutic strategy for CVD and IS. However, despite intensive statin therapy, a significant proportion of high-risk hypercholesterolemic patients fail to achieve sufficient reductions in LDL-C levels. In response to this challenge, an inhibitor targeting proprotein convertase subtilisin-kexin type 9 (PCSK9) has been developed as a therapeutic intervention for hyperlipidemia. Numerous randomized controlled trials (RCTs) have conclusively demonstrated that the combination of PCSK9 inhibitors and statins significantly enhances prognosis not only in patients with CVD, but also in those afflicted with symptomatic intracranial artery stenosis (sICAS). PCSK9 inhibitors significantly reduce LDL-C levels by binding to the PCSK9 molecule and preventing its interaction with LDLRs. This prevents degradation of the receptor and increases uptake of LDL-C, thereby decreasing its concentration in blood. Besides significantly reducing LDL-C levels, PCSK9 inhibitors also demonstrate anti-inflammatory and anti-atherosclerotic properties while promoting plaque stabilization and inhibiting platelet aggregation and thrombosis. This article aims to provide a comprehensive review based on the relevant literature regarding the evolving understanding of pleiotropic effects associated with PCSK9 inhibitors, particularly focusing on their impact on the cardiovascular system and central nervous system. Full article

Background/Objectives: A significant gap exists between guideline recommendations and everyday practice. Stringent treatment is needed for vulnerable patients with acute coronary syndrome (ACS). Methods: Data on the lipid-lowering therapy (LLT), including the adherence, persistence, and mortality of patients undergoing percutaneous coronary intervention or bypass surgery in Hungary in 2018 were followed up and analyzed based on the National Health Insurance Fund database until the end of 2020. Results: A total of 12,997 patients underwent revascularization for ACS in 2018, whose discharge therapy included any LLT, a high- or moderate-intensity statin, or ezetimibe at a proportion of 91%, 75%, 12%, and 4%, respectively. By the end of the observation period, the frequency of ezetimibe administration increased to 11%. Persistence decreased, reaching 50% for all therapeutic regimens by month 16. Patients on moderate statin doses had a significantly higher mortality rate at the end of follow-up than those receiving high-intensity statin with (20% vs. 9%, p < 0.0001) or without (20% vs. 14%, p = 0.00029) ezetimibe. Those taking less potent statin doses had higher rates of comorbidities; for example, a minimum of three comorbidities were present in 39% of patients taking medium statin doses and 23% among those on high-intensity statin therapy (p < 0.0001). Conclusions: LLT persistence decreased during follow-up. The administration of a higher-intensity lipid-lowering regimen was associated with better persistence and adherence, along with more favorable mortality rates. Multimorbidity was associated with the use of lower statin doses. The results suggest that more attention is needed in terms of lipid control of females, elderly people, and individuals with several comorbidities, and emphasis should be placed on improving persistence and increasing the frequency of combined LLT prescriptions. Full article

Background: Recent data from European studies (EUROASPIRE V, DA VINCI, SANTORINI) indicate that achieving the LDL cholesterol (LDL-C) target in patients at very high cardiovascular risk is uncommon. Additionally, using a combination therapy involving statins and ezetimibe remains infrequent. Methods: A single-center assessment of a pre-defined lipid lowering treatment algorithm’s effectiveness at achieving the LDL-C target in patients at very high cardiovascular risk one month and one year after hospitalization. Results: 81 patients were included, all in secondary prevention. The average age of the patient was 66.9 years, and the main cardiovascular risk factors included hypertension, diabetes mellitus, and smoking history. Following the predefined lipid-lowering algorithm specific to our study, which involves initiating high-intensity statin therapy or a combination of statin and ezetimibe depending on initial LDL-C levels and patient history; 30 (37%) patients initiated high-intensity statin therapy (Atorvastatin (40 mg, 80 mg) or Rosuvastatin (20 mg, 40 mg)), while 51 (63%) started combination therapy with high-intensity statin and ezetimibe 10 mg. After one year, 57 (70.4%) remained adherent to their initial treatment, achieving a mean LDL-C of 49.5 ± 16.9 mg/dL, with 36 (63.2%) of them reaching the LDL-C target of <55 mg/dL. A total of 13 patients discontinued treatment, and 9 were lost to follow-up, withdrew from the study, or died. Conclusion: Initiating dual statin and ezetimibe therapy or high-intensity statin therapy early, based on the expected treatment efficacy, holds the potential to more rapidly and effectively achieve LDL-C targets in a larger proportion of very high-risk cardiovascular patients. Full article

Background and Objectives: Patients with previous acute myocardial infarction are at significantly higher risk of recurrent events. Early and intensive lipid-lowering therapy targeting low-density lipoprotein cholesterol is a key strategy for reducing cardiovascular risk in post-acute myocardial infarction patients worldwide. This study aimed to assess patients’ real-life lipid-lowering treatment gaps after acute myocardial infarction using a global network, TriNetX, of anonymous, real-time patient data. The uniqueness of the study was the use of the novel, evolving, and constantly improving TriNetX platform and the evaluation of its feasibility for clinical research. Materials and Methods: A retrospective study was conducted on global repository patients in 2020, diagnosed with acute myocardial infarction, with a three-year follow-up. Results: After acute myocardial infarction, the prescribing rate of lipid-lowering medication (statins, ezetimibe and PCSK9I) was insufficient to reach target LDL-C values. The mean LDL-C level decreased from 2.7 mmol/L (103 mg/dL) as measured on the day of AMI to 1.97 mmol/L (76 mg/dL) between 31D and 3M. During the second and third years, the mean LDL-C value was stable (around 2.0 mmol/L (78 mg/dL)). LDL-C goals were not sufficiently reached, as only 7–12% of patients were reported to have LDL-C values < 55 mg/dL (1.4 mmol/L) and 13–20% of patients were reported to have LDL-C values < 70 mg/dL (1.8 mmol/L) during the follow-up periods. This means that a substantial number of patients remain at a very high risk for CV complications and mortality. Most cardiovascular complications happen within three months after acute myocardial infarction. Conclusions: Gaps remain between the recommendations for managing LDL-C in guidelines and what occurs in real life. The TriNetX platform is an innovative platform with significant potential and should be further developed for clinical research, as it enables the use of valuable interinstitutional data. Full article

Objectives: Secondary prevention is crucial for reducing morbidity and mortality in patients following acute myocardial infraction (MI). However, adherence to cardiac rehabilitation (CR) and pharmacotherapy remains suboptimal despite strong guideline recommendations. This study investigated the adherence to CR, dual antiplatelet therapy (DAPT), and statins following acute MI and evaluated their impact on patient outcomes from a nationwide perspective in Austria. Methods: In this national observational study, all patients diagnosed with acute MI, defined as STEMI or NSTEMI, between April 2011 and August 2015 in Austria were included. Patient characteristics and comorbidities were derived from the Austrian national health insurance system using ICD-10 codes. Adherence to CR, high-intensity statins, and DAPT was assessed based on health insurance records and pharmacy prescription submissions. Cox Regression hazard analysis was used to explore the impact of non-adherence to CR on mortality. Results: Among 16,518 acute MI patients, only 13.4% adhered to the recommended CR programs, which was associated with a significantly lower risk of mortality (adjusted hazard ratio [HR] 0.73; 95% CI: 0.54–0.98; p = 0.036). In contrast, 66.4% of 23,240 patients did not comply with high-intensity statin therapy, correlating with an increased mortality risk (adjusted HR 1.16; 95% CI: 1.06–1.25; p < 0.001). Furthermore, among 22,331 patients analyzed for DAPT adherence, only 29.3% followed the guidelines, yet this adherence was linked to a 21% reduction in mortality over the observation period (adjusted HR 0.79; 95% CI: 0.72–0.88; p < 0.001). Conclusions: This nationwide study reveals alarmingly low adherence to CR and secondary preventive medications among acute MI patients, which is significantly linked to higher mortality rates. Enhanced efforts to promote awareness and adherence are crucial, involving structured referrals and personalized follow-ups to improve patient outcomes. Addressing these gaps through comprehensive healthcare strategies could substantially enhance cardiovascular health. Full article

Background: Real-world data on the use of lipid-lowering therapy (LLT) in clinical practice show that about 80% of (very) high-cardiovascular (CV)-risk patients disregard the 2019 European Society of Cardiology (ESC) Guidelines’ recommendations on dyslipidemias. The availability of proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (PCSK9mAb) should reduce this gap. Our aim was to provide data on PCSK9mAb use in clinical practice, investigating the achievement of the ESC Guidelines’ recommendations in the real world. Methods: Between April 2018 and December 2022, patients who started on PCSK9mAb therapy (140 mg of evolocumab or 75 mg or 150 mg of alirocumab, subcutaneous injection every 2 weeks) were included in a prospective registry. Our cohort consisted of 256 patients: 95 (37.1%) were women (mean age: 65.43 ± 11.12 yrs), 53 (20.7%) were at high CV risk, and 203 (79.3%) were at very high CV risk. Results: After one year of PCSK9mAb treatment, nearly 60% of patients demonstrated full adherence to the ESC Guidelines’ recommendations, defined as achieving at least a 50% reduction in low-density lipoprotein cholesterol (LDL-C) levels along with reaching LDL-C target levels (≤55 and ≤70 mg/dL for very high and high risk, respectively). Concomitant high-dose statin therapy emerged as the primary predictor of LDL-C target attainment. Heterozygous familial hypercholesterolemia (HeFH), statin intolerance, and female gender were associated with a significant lower probability of achieving LDL-C target levels. Conclusions: Our analysis confirms that PCSK9mAb treatment is safe and effective, enabling 60% of our cohort to fully achieve the LDL-C guideline recommendations. The use of high-intensity statins emerged as a significant predictor of efficacy. Conversely, familial hypercholesterolemia and female gender were identified as predictors of therapeutic failure. Hence, it is crucial to address disparities in cardiovascular disease prevention between genders and to enhance strategies for managing elevated LDL-C in HeFH patients. Full article

Background and Objectives: Lowering low-density lipoprotein (LDL-C) levels is critical for preventing atherosclerotic cardiovascular disease, yet some patients fail to reach the LDL-C targets despite available intensive lipid-lowering therapies. This study assessed the effectiveness and safety profile of alirocumab, evolocumab, and inclisiran in lipid reduction. Materials and Methods: A cohort of 51 patients (median (Q1–Q3) age: 49.0 (39.5–57.5) years) was analyzed. Eligibility included an LDL-C level > 2.5 mmol/L while on the maximum tolerated dose of statin and ezetimibe, a diagnosis of familial hypercholesterolemia, or a very high risk of cardiovascular diseases following myocardial infarction within 12 months prior to the study. Follow-ups and lab assessments were conducted at baseline (51 patients), 3 months (51 patients), and 15 months (26 patients) after the treatment initiation. Results: Median initial LDL-C levels 4.1 (2.9–5.0) mmol/L, decreasing significantly to 1.1 (0.9–1.6) mmol/L at 3 months and 1.0 (0.7–1.8) mmol/L at 15 months (p < 0.001). Total cholesterol also reduced significantly compared to baseline at both intervals (p < 0.001). No substantial differences in LDL-C or total cholesterol levels were observed between 3- and 15-month observations (p > 0.05). No statistically significant differences were noted in cholesterol reduction among the alirocumab, evolocumab, and inclisiran groups at 3 months. The safety profile was favorable, with no reported adverse cardiovascular events or significant changes in alanine transaminase, creatinine, or creatine kinase levels. Conclusions: Alirocumab, evolocumab, and inclisiran notably decreased LDL-C and total cholesterol levels without significant adverse effects, underscoring their potential as effective treatments in patients who do not achieve lipid targets with conventional therapies. Full article

Lipid-lowering therapy (LLT) is a cornerstone of atherosclerotic cardiovascular disease prevention. Although LLT might lead to different reductions in low-density lipoprotein cholesterol (LDL-C) levels in women and men, LLT diminishes cardiovascular risk equally effectively in both sexes. Despite similar LLT efficacy, the use of high-intensity statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors is lower in women compared to men. Women achieve the guideline-recommended LDL-C levels less often than men. Greater cholesterol burden is particularly prominent in women with familial hypercholesterolemia. In clinical practice, women and men with dyslipidemia present with different cardiovascular risk profiles and disease manifestations. The concentrations of LDL-C, lipoprotein(a), and other blood lipids differ between women and men over a lifetime. Dissimilar levels of LLT target molecules partially result from sex-specific hormonal and genetic determinants of lipoprotein metabolism. Hence, to evaluate a potential need for sex-specific LLT, this comprehensive review (i) describes the impact of sex on lipoprotein metabolism and lipid profile, (ii) highlights sex differences in cardiovascular risk among patients with dyslipidemia, (iii) presents recent, up-to-date clinical trial and real-world data on LLT efficacy and safety in women, and (iv) discusses the diverse medical needs of women and men with dyslipidemia and increased cardiovascular risk. Full article

Cardiovascular disease (CVD), particularly coronary heart disease (CHD), is the leading cause of death in the US, with a high economic impact. Coronary artery calcium (CAC) is a known marker for CHD and a useful tool for estimating the risk of atherosclerotic cardiovascular disease (ASCVD). Although CACS is recommended for informing the decision to initiate statin therapy, the current standard requires a dedicated CT protocol, which is time-intensive and contributes to radiation exposure. Non-dedicated CT protocols can be taken advantage of to visualize calcium and reduce overall cost and radiation exposure; however, they mainly provide visual estimates of coronary calcium and have disadvantages such as motion artifacts. Artificial intelligence is a growing field involving software that independently performs human-level tasks, and is well suited for improving CACS efficiency and repurposing non-dedicated CT for calcium scoring. We present a review of the current studies on automated CACS across various CT protocols and discuss consideration points in clinical application and some barriers to implementation. Full article